Empathy from
the outside in
The missing internal foundations of medical communication skills curricula
Author:
Mahé Pereira, MD, and Ana Claudia Alves-Nogueira, PhD (University of Coimbra)
Status:
Complete draft, in active co-author collaboration — not yet submitted.
Target journal:
Academic Medicine
ABSTRACT:
Communication skills training is embedded across medical education globally, yet empathy (one of the most critical competencies in clinical practice) declines during training. This perspective argues that the dominant communication frameworks (Calgary-Cambridge, Kalamazoo, CanMEDS, ACGME) are behaviorally structured: they teach observable empathic outputs without developing the internal capacities from which genuine empathic engagement emerges. Drawing on contemporary neuroscience, this paper identifies two foundational capacities that are structurally absent from these curricula: interoceptive awareness, the perception and integration of internal physiological signals that generate emotional experience; and explicit emotion regulation, the deliberate modulation of affective states that determines whether interoceptive sensitivity becomes clinical attunement or emotional overwhelm. The paper proposes three specific curricular additions: structured interoceptive training (body-oriented practices such as Focusing), explicit emotion regulation education using dual-process frameworks, and intentional sequencing that builds internal capacities before behavioral skills practice. These are not replacements for existing frameworks but prerequisites for making them work as intended.